{"id":1609,"date":"2013-10-11T09:55:30","date_gmt":"2013-10-11T09:55:30","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1609"},"modified":"2013-10-11T09:55:30","modified_gmt":"2013-10-11T09:55:30","slug":"urinary-incontinence-lecture-notes","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/mlove\/curriculumwomengeri-2\/incontinence\/incontinence-articles\/urinary-incontinence-lecture-notes\/","title":{"rendered":"URINARY INCONTINENCE Lecture Notes"},"content":{"rendered":"

 <\/p>\n

\n

\u00a0<\/p>\n

URINARY
\nINCONTINENCE<\/span><\/h1>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

Prevalence
\nand Cost<\/span><\/h2>\n

\u00a0<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Incontinence affects approximately13
\nmillion Americans.\u00a0 <\/span>Reported prevalence
\nrates vary considerably; among the population between 15 and 64 years old, the prevalence
\nof UI in men ranges from 1-5%, in women from 10-30%.\u00a0 <\/span>For the non-institutionalized elderly, prevalence estimates range
\nfrom 15-35% with women having at least twice the prevalence of men.\u00a0 <\/span>The prevalence in nursing homes is greater
\nthat 50%.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Cost estimates for caring for
\nincontinent adults are in the billions.
\n<\/span>About one billion is spent annually on incontinence products (diapers,
\netc.) alone.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Incontinence often ruins or distorts
\npatients\u2019 lifestyles.\u00a0 <\/span>Patients are
\nquite distressed by and will go to great lengths to avoid the associated
\nembarrassment.<\/span><\/p>\n

\u00a0<\/p>\n

Anatomy
\nand Physiology of the Bladder and Urethra<\/span><\/h2>\n

\u00a0<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Basically the bladder is a
\nmuscular bag (The detrusor) with a sphincter.
\n<\/span>The bladder has a serosal layer, a muscle layer, and a mucosal layer of
\ntransitional epithelium.<\/span><\/p>\n

The
\nurethra extends from the bladder neck to the meatus, a distance of 4 cm in
\nwomen, and 20 cm in men.\u00a0 <\/span>Two smooth
\nmuscles run longitudinally along the urethra and form a functional internal
\nsphincter.\u00a0 <\/span>The striated external sphincter
\nallows voluntary interruption of voiding.
\n<\/span>In women the geometry of the urethrovesical junction and the proximal
\nurethra is important in maintaining continence.\u00a0 <\/span>Normally, the pelvic floor muscles, especially the levator ani,
\nare in a constant state of contraction and support the bladder neck so that
\nthere is a 90 Degree angle.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The neuroanatomy is complicated (see
\nFigure), but can be reduced to the following two clinically important details.<\/span><\/p>\n

i)
\n<\/span><\/span>The
\ndetrusor muscle has Acetylcholine receptors; when these are stimulated the
\ndetrusor contracts.<\/span><\/p>\n

ii)
\n<\/span><\/span>The
\nsphincter muscles have a alpha-1 adrenergic receptors; when stimulated, the
\nsphincters constrict.<\/span><\/p>\n

In
\nmore detail:\u00a0 <\/span>Three sets of nerves
\ncontrol the bladder.\u00a0 <\/span>The
\nparasympathetic originate from the spinal cord at S2-4 and travel to the
\nbladder via the pelvis nerves.\u00a0 <\/span>These
\nnerves synapse with cholinergic receptors in the bladder wall, bladder outlet
\nand urethra.\u00a0 <\/span>They cause detrusor contraction
\nand inhibit sympathetic activity.\u00a0 <\/span>The
\nsympathetics originate from T11-L2 and travel via the hypogastric nerves.\u00a0 <\/span>They stimulate alpha-adrenergic receptors
\nlocated in the bladder outlet and the urethra (internal sphincter
\ncontraction).\u00a0 <\/span>They also stimulate
\nbeta-receptors in the detrusor, which cause bladder relaxation.\u00a0 <\/span>Somatic nerve fibers arising from S2-4
\ntravel via the pudenal nerve and supply the external sphincter (voluntary
\ncontrol) and the pelvic floor.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>In the brain, there are two important
\nloci.\u00a0 <\/span>The pontine micturion center
\n(PMC) coordinates the relaxation of the sphincters with the contraction of the
\nbladder.\u00a0 <\/span>The frontal lobe provides
\ntonic inhibition of the PMC.<\/span><\/p>\n

\u00a0<\/h3>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

\u00a0<\/h3>\n

NORMAN MICTURITION<\/span><\/h3>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Initially, urine accumulates
\nin the bladder at low intravesicular pressures.\u00a0 <\/span>As the volume of urine approaches 25-300 ml, the pressure begins
\nto rise sharply.\u00a0 <\/span>Bladder afferents
\ntravel through the pelvic nerves to the spinal cord bearing the message
\n\u201cBladder full.\u201d\u00a0 <\/span>This message ascends
\nvia the spinal cord to the PMC and the frontal lobe, at which point the person
\nbecomes aware of the need to void.\u00a0\u00a0 <\/span>The
\nfrontal lobe inhibits the PMC until an appropriate place to urinate<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The voluntary effort of voiding begins
\nwith cessation of inhibition from the frontal lobe.\u00a0 <\/span>The PMC coordinates increased parasympathetic activity and
\ninhibited sympathethic activity.\u00a0 <\/span>This
\nresults in bladder contraction and relaxation of the sphincters.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

NORMAL CONTINENCE<\/span><\/h4>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>There are several levels
\nwhich need to be intact to maintain normal continence.<\/span><\/p>\n

Sometimes
\nif there is a problem at one level, the others can compensate but usually not.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The PMC must receive inhibition from
\nthe frontal lobe.\u00a0 <\/span>Strokes, dementia,
\nand delirium can affect this.\u00a0 <\/span>Without
\nfrontal lobe inhibition, the patient urinates the full bladder volume when the
\npressure begins to distend it.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The spinal cord must be intact to
\ntransmit all these signals.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Spontaneous bladder contractions must
\nbe inhibited by the sympathetics.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Sympathetically medicated sphincter
\ncontraction must be present.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The ureterovesical angle must be
\npreserved by the pelvic floor muscles.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0<\/span><\/h4>\n

TYPES OF
\nESTABLISHED URINARY INCONTINENCE<\/span><\/h4>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The types discussed here are all
\nexamples of established, chronic incontinence<\/em> in ambulatory
\npatients.\u00a0 <\/span>We will discuss causes of transient\/new<\/em><\/strong>
\nincontinence and incontinence<\/em> in demented\/institutionalized patients<\/em>
\nelsewhere.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Stress Incontinence<\/span><\/strong><\/p>\n

\u00a0<\/span><\/p>\n

This is the second most common cause of incontinence in
\nwomen but rare in men (except when the internal sphincter is damaged by
\nsurgery).\u00a0 <\/span>Stress\u00a0 <\/span>UI is defined as the involuntary loss of
\nurine occurring when the intravesical pressure exceeds urethral pressure in the
\nabsence of detrusor contraction.\u00a0 <\/span>This
\nusually occurs when intra-abdominal pressure abruptly increases, often with
\nposition change, coughing, sneezing and laughing.\u00a0 <\/span>This loss of thickness-together with the loss of the
\nurethrovesical 90 degree angle resulting from laxity of the pelvic floor
\nmuscles (from aging, multiparity, surgery) \u2013 lead to stress UI.\u00a0 <\/span>The potential targets of therapy are apparent-estrogen
\ndeficiency, pelvic floor muscle tone, bladder position, and sphincter tone.<\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Urge Incontinence<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

This is the most common cause of incontinence.\u00a0 <\/span>The essential problems here are uninhibited
\nbladder contractions of strength sufficient to overcome urethral
\nresistance.\u00a0 <\/span>The pathogenesis is not
\nentirely worked out.\u00a0 <\/span>But basically, as
\nthe bladder ages, the innervation of the detrusor becomes less dense and
\neffective, particularly the sympathetically medicated inhibition
\ncontractions.\u00a0 <\/span>Spontaneous contractions
\nmedicated by reflex are through the spinal cord start to occur at bladder
\nvolumes of 250cc or so.\u00a0 <\/span>Normally these
\nare inhibited by inputs from the PMC, but in aging bladder they may not be and
\nthus a full bladder contraction may occur when the patient doesn\u2019t want it
\nto.\u00a0 <\/span>This is called Detrusor
\nInstability.\u00a0\u00a0 <\/span>It\u2019s sort of like a\u00a0 <\/span>PVC of the bladder.\u00a0 <\/span>Therapies are targeted at maintaining
\nvoluntary control over the sphincter and inhibiting the bladder PVC\u2019s.<\/p>\n

\u00a0<\/p>\n

Overflow Incontinence<\/h5>\n

\u00a0<\/span><\/p>\n

Involuntary
\nloss of urine associated with over distention of the bladder.\u00a0 <\/span>Usually results from prolonged bladder
\noutlet obstruction, most often from BPH.
\n<\/span>To continue the cardiologic analogy, this is sort of like aortic
\nstenosis of the bladder.\u00a0 <\/span>Eventually the
\nbladder (like the left ventricle) hypertrophie and dilates; the \u201cejection
\nfraction\u201d drops, and the bladder fails.
\n<\/span>At this point the bladder is chronically full and slowly and
\ncontinuously leaks through the stenosis.
\n<\/span>Overflow incontinence can also result from detrusor hypotonia (analogous
\nto a primary cardiomyopathy) usually from diabetic neuropathy.\u00a0 <\/span>Therapy is directed at relieving the
\nobstruction or increasing bladder contractility.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Incontinence Associated with
\nCNS Disease<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

Strokes,
\ndementia, and other CNS disease can result in loss of frontal lobe inhibition
\nof the PMC.\u00a0 <\/span>Therapy is primarily
\nbehavioral and directed at keeping the bladder empty through scheduled frequent
\ntoileting.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0<\/p>\n



\n<\/span><\/p>\n

TRANSIENT CAUSES
\nOF INCONTINENCE<\/span><\/h4>\n

\u00a0<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Transient Incontinence occurs in up to
\none third of the community dwelling elderly and up to half of acutely
\nhospitalized elderly patients.\u00a0 <\/span>Whenever
\na diagnosis of incontinence is made, a search for these reversible causes should
\nbe undertaken.\u00a0 <\/span>One mnemonic for remembering
\nthe causes of transient incontinence is:<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>D<\/strong>elirium<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>I<\/strong>nfection<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>A<\/strong>trophic Vaginitis<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>P<\/strong>harmaceuticals- diuretics,
\nalpha blockers, calcium channel blockers,
\n<\/span><\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>\u00a0\u00a0\u00a0\u00a0 <\/span>anticholinergics sedatives, alcohol<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>E<\/strong>xcess urine output \u2013from
\ndiabetes or diuretics ( including coffee and EtOH)<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>R<\/strong>estricted Mobility- continence
\nis a functional behavior-e.g. an ankle fracture\u00a0 <\/span>may make a patient with previously marginal continence
\nincontinent by slowing them down.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>S<\/strong>tool Impaction-\u00a0 <\/span>the rectal mass may stimulate bladder
\ncontractions<\/span><\/p>\n

\u00a0<\/span><\/p>\n



\n<\/span><\/p>\n

DIAGNOSIS<\/span><\/h4>\n

\u00a0<\/span><\/strong><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Diagnosis is mostly by
\nhistory and physical.\u00a0 <\/span>If further
\ntesting is needed, urodynamic testing can be performed.\u00a0\u00a0 <\/span>Usually the incontinence can be classified
\n(as stress, urge, or mixed) on basis of H & P alone and appropriate treatment
\ninitiated.<\/h2>\n

\u00a0<\/h2>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>History<\/span><\/h2>\n

\u00a0<\/span><\/p>\n

An
\naccurate voiding history is essential<\/em>indetermining the etiology of
\nincontinence.\u00a0 <\/span>Ask about:<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Volume of urine loss<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Body position in which the urine loss
\noccurred<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Aggravating conditions such as cough,
\nsneeze, exertion<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Urgency, frequency, dysuria, nocturia,
\nhesitancy, straining, dribbling<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Warning<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Other medical history- menstrual,
\nparity, CHF, DM, CNS disease, meds<\/span><\/p>\n

\u00a0<\/span><\/p>\n

The
\ntypical history for pure stress incontinence is loss of small amounts of urine precipitated
\nby cough, sneeze, laugh or strain.\u00a0 <\/span>The
\ntypical history for urge incontinence is sudden loss of large amounts of urine
\n(full bladder volume) preceded by an urge to void and inability to make it to
\nthe toilet fast enough.\u00a0 <\/span>Often patients
\nreport urinating at the sound of running water or in association with other
\ntoileting cues.\u00a0 <\/span>The typical history for
\noverflow incontinence is of near constant dribbling of small amounts of urine
\nassociated with sensation of abdominal fullness and incomplete emptying; the
\npatient is usually not aware that the urine is leaking.\u00a0 <\/span>Many patients have mixed incontinence with
\nfeatures of both urge and stress.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Physical Exam<\/span><\/strong><\/p>\n

\u00a0<\/span><\/p>\n

In
\naddition to route exam, an abdominal exam to rule bladder distention, a pelvic
\nexam (looking for atrophic vaginitis, pelvic floor laxity, cystocele), a rectal
\nexam (to rule out stool impaction) and neurologic exam are indicated.<\/span><\/p>\n

\u00a0<\/span><\/strong><\/p>\n

Post Void Residual Volume<\/h5>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>The volume of urine
\nremaining in the bladder after the patient voids voluntarily.\u00a0 <\/span>This is high with BPH\/overflow incontinence
\nand low otherwise.\u00a0 <\/span>It can be checked by
\ninserting a foley catheter or by sonogram (order bladder ultrasound, specify
\n\u201cestimate PVR\u201d).<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Urinalysis\/Urine Culture<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

To rule out infection, glycosuria<\/h2>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Urodynamics<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

Functional
\nexam of bladder performed when above do not yield clear diagnosis or attempts
\nat therapy are unsuccessful.\u00a0 <\/span>Usually
\nperformed by specialists (urology or gynecology), but can be easily done by the
\nmotivated internist.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>A foley is inserted and sterile saline
\nis used to fill the bladder while measuring instilled volume and measuring
\npressure.\u00a0 <\/span>Threshold volumes for first
\ndesire to void, strong desire to void, detrusor contractions, and bladder
\ncapacity are recorded.\u00a0 <\/span>The catheter is
\nthen removed and provocative tests for stress incontinence are performed \u2013 the
\npatient stands up and coughs or strains as a paper towel is held under to see
\nif drops of urine leak out.<\/span><\/p>\n

\u00a0<\/p>\n

TREATMENT<\/span><\/h4>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Behavioral, pharmacologic,
\nand surgical treatments are available for all types of incontinence.\u00a0 <\/span>In general, they are roughly equally
\nefficacious.\u00a0 <\/span>In weighing the options,
\nthe usual pros and cons apply;\u00a0 <\/span>Behavioral
\napproaches require motivated patients.
\n<\/span>The drugs have significant systemic side effects.\u00a0 <\/span>Surgery has its risks, costs, complications
\nand failures.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Stress Incontinence<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Behavioral therapy is
\nprimarily pelvic floor training, most commonly with Kegel exercises (see
\nattached).\u00a0 <\/span>The goal of pelvic floor exercises
\nis to the increase the strength of the levator ani muscle in order to maintain
\nthe urethrovesical angle \u2013 see the attachment.
\n<\/span>Biofeedback can also be used to help the patient get started.\u00a0 <\/span>The exercises work \u2013 the majority of
\nmotivated patients will require no additional treatment.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Pharmacologic therapy is directed at
\nenchancing the function of the internal sphincter.\u00a0 <\/span>Estrogen, administered intravaginally or orally, can reverse the
\nthinning of the urethral mucosa.\u00a0 <\/span>Alpha
\nagonists can tighten up the sphincter \u2013 commonly used meds are low dose
\ntricyclics (imiprmine or amitriptyline, both of which have anticholinergic
\nactivity as well) and psudoephedrine.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Surgery aims to restore the proper
\narchitecture of the pelvis.\u00a0 <\/span>There are
\nvarious procedures for resuspending or slinging the bladder; different surgeons
\nfavor different operations.
\n<\/span>Intraurethral injections of collagen are also done.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Urge Incontinence<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Behavioral therapy for UUI
\nconsists of both pelvic floor training as described above and various forms
\nbladder training.\u00a0 <\/span>The idea behind
\nbladder training is to restore a normal pattern of voiding and normal bladder
\nfunction.\u00a0 <\/span>Initially the patient is
\ninstructed to void at fixed intervals, usually every 30-60 minutes regardless
\nof whether or not the urge to void is present.
\n<\/span>(The initial interval can be determined using a voiding diary.)\u00a0 <\/span>If an urge to void occurs prior to the next
\nschedule time, the patient is instructed to suppress the urge by attempting to
\nrelax (often with a relaxation technique) or to distract herself.\u00a0 <\/span>Each week the interval is increased until
\ncontractions and can increase bladder capacity over the interval is increased
\nuntil a normal voiding pattern is stained.
\n<\/span>As with Stress UI, the motivated get good results.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Pharmacologic therapy is
\nanticholinergics, which suppress involuntary bladder contractions and can
\nincrease bladder capacity over the long term.
\n<\/span>Anticholinergics are reasonably effective but side effects (dry mouth,
\nurinary retention, constipation, blurred vision, propantheline (probanthine 15
\nmg tid or qid), oxybutinin (ditropan 2.5mg bid or oxybutinin XL 5 qd), and
\ntolterodine (detrol 1 mg bid).\u00a0 <\/span>Increase
\ndose as tolerated.\u00a0 <\/span>Generally, it takes
\nweeks to realize full benefit of the drug.<\/span><\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>There are no good surgical options.<\/span><\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Overflow Incontinence<\/span><\/strong><\/p>\n

\u00a0<\/p>\n

Treatment consists of relieving the obstruction if one is
\npresent and trying to enhance bladder contractility with pro-cholinergic oral
\nmeds (urocholine).\u00a0 <\/span>\/this is often
\nineffective and placement of a suprapubic tube may be necessary.<\/p>\n

\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Incontinence Associated with
\nCNS Disease<\/span><\/strong><\/p>\n

\u00a0<\/span><\/p>\n

The only available treatment is behavioral.\u00a0 <\/span>Showing the patient to the bathroom and
\nprompting them to void at regular intervals can reduce the frequency and
\nseverity of incontinence episodes.\u00a0 <\/span>Remember
\nto ask the caregivers about incontinence.
\n<\/span>They may not mention it and it\u2019s often one of the factors that drives
\notherwise motivated caregivers to institutionalize their family members.\u00a0 <\/span>Prescribe adult diapers, plastic underpants,
\nchux, non-sterile gloves, and mattress liners and provide support to the
\ncaregivers.<\/p>\n

<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

  \u00a0 URINARY INCONTINENCE \u00a0 \u00a0 Prevalence and Cost \u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Incontinence affects approximately13 million Americans.\u00a0 Reported prevalence rates vary considerably; among the population between 15 and 64 years old, the prevalence of UI in men ranges from 1-5%, in women from 10-30%.\u00a0 For the non-institutionalized elderly, prevalence estimates range from 15-35% with women having….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1474,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1609","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1609","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1609"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1609\/revisions"}],"predecessor-version":[{"id":1610,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1609\/revisions\/1610"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1474"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1609"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}